Thursday, October 16, 2008

Avid readers of this humble blog should know by now the sort of fodder that boils up a Thinking Is Dangerous blogpost - dodgy quack medicines being touted as wonderdrugs, newspapers taking no notice of integrity and printing anything that pops into their inbox, the rubber-toothed fight by the Advertising Standards Authority to keep things in check, that sort of thing.

Once in a while, a story pops up which presses all the buttons, and with only a whisper of fat-fingered googling, I can sit in amazement watching the pieces of the story happily fall into place like a Christmas morning jigsaw.

Once again we'll turn the TID spotlight to arthritis, the Daily Mail, the ASA, and pretty pennies being made.

Modern medicine, although coming on leaps and bounds, is still a bit duff when it comes to diseases like arthritis. Outwith mechanical intervention, pain management is about all there is, and even then, the painkillers can have side effects and long term effects that aren't much fun.

Put yourself in that position - constant chronic pain, only slightly eased by medication - and suddenly old wives tales, exotic berries and other natural products seem to hold the answer. We can't hope for pill-pushers and nonsense therapy merchants to have much proof, because people buy the dream, not the evidence. We need medicine and knowledge that is evidence-based to be able to base our pain-management approach on treatments that have been shown to be effective. Otherwise, we're throwing our money at the moon.

We start the rosy story off with the Daily Mail, providing another excellent candidate for Dr* T's First Theory as it announces:

Why so many touts for the humble hedgerow habitant, rosa canina? Well, it should take you less than 5 seconds to realise that the connection between all the touts is a product called LitoZin.

Here are a few quotes from the Daily Mail report:

A herbal medicine made from rosehips may regenerate joints in people crippled by arthritis, say scientists.Studies show it can protect the cartilage cells which facilitate joint movement. Researchers claim the red hips - one of nature's richest sources of vitamin C - also improve activity levels by damping down an over-active immune system.

The Swiss studies looked at the action of the sugary fatty acid GOPO, the active ingredient in the rosehip supplement LitoZin. Researchers from the department of human nutrition and health in Basle, Switzerland, measured the effects of different doses on human cartilage cells.

The Department of Human Nutrition & Health in Basel, eh? Which university is that associated with, or indeed, why doesn't it say the name of the organisation? That's probably because the scientists are part of the Department of Human Nutrition & Health at DSM Nutritional Products, Basel, who manufacture i-Flex (nothing to do with Apple) which is marketed in Europe as .... LitoZin. (Press release here)

What a surprise. Now why was that bit left out of the Daily Mail report? The trademark is actually held by Dansk Droge, a Danish company, and perhaps why a lot of the Daily Mail articles refer to scientists in Copenhagen.

Now let me make two important points - firstly, the research may be of an astounding quality and impeccable beyond reproach. However, the fact that Daily Mail hides this information makes me think maybe it isn't. Also the fact that it is "announced at the Osteoarthritis Research Society's International World Congress in Rome" rather than in a peer-reviewed research journal means it's difficult to find out what went on. Secondly, there may well be some active ingredient in rosehips worth looking at, but, as I said above, with products like these, good research does little to enhance the sales, because people are buying a dream, regardless of the evidence. (I'll also remind you that we arthrites seem to be particularly susceptible to placebo). Why bother putting together a large well-run trial, when the same sales can be achieved by 2 or 3 small irrelevant ones?

So to recap, Daily Mail has published, on 5 separate occasions PR fluff from DSM (or their UK distributors - LanesHealth www.litozin.co.uk, or online from www.arthritis-relief.co.uk) citing little/no firm evidence but being suspiciously cagey about where the evidence came from. Such is the state of churnalism in the UK press - the stories we read are there because they help line the pockets of the pill peddlers (and their PR agents) and nothing to do with public service, furtherance of scientific advances or importantly, helping people suffering from arthritis, except to empty their wallets.

One organisation who decided the evidence is absent, is the bastion of company's claims in print and other media, the Advertising Standards Authority. I've written about the ASA on a number of occasions, and praise them from the rooftops. My angst with them is that they have no power and no bite, save producing indirectly a few bits of negative PR.

Healthy Marketing Ltd (trading as Woods Supplements) came up against the ASA this week (15th Oct 2008). A direct mail catalogue had a claim, headlined "Rose-Hips may Ease Arthritic Pain ... ", appearing next to an image of the Daily Mail article headlined "Are rose-hips the answer to the agony of arthritis?", which stated rose hips had an unknown active ingredient that affected the blood cells involved in inflammatory and immune responses. The catalogue contained a myriad of en vogue health supplements which you can enjoy at your leisure.

According to the adjudication, Woods Supplements provided information, abstracts or the references of studies related to the properties of each supplement, including the Rosehip pills, to which the ASA summed up as follows:

We noted some references to clinical trials but that there was not enough information for us to assess whether the trial was valid or supported the claims. We therefore considered the information provided was insufficient to substantiate the claims made about the benefits of the supplements. We concluded the claims had not been substantiated and were therefore misleading.

So there you have it. Unsubstantiated and misleading. In the interests of disclosure, I should mention that I eat rosehip syrup quite often. Not for arthritis, but because rosehip syrup is easy to make, cheap and fantastically tasty with greek yoghurt. Maybe one day the pill peddlers will carry out a well-run clinical trial on rosehips which will warrant me to really indulge.

Saturday, October 11, 2008

At the risk of invoking a variant of Dr*T's First Theory, I'd honestly like your opinion on the following:

This week, I blogged about the GAIT trial, or Glucosamine/Chondroitin Arthritis Intervention Trial, which was a large randomized, placebo-controlled trial conducted at several sites across the USA comparing glucosamine & chondroitin with placebo and paracetomol for arthritis.

We've got the trial out of the way and we know that the results, although interesting, really confirm what we already knew about glucosamine, in that it's not a magic pill. It's just a pill. A pill that us highly suggestive arthrites rely on, perhaps, for pain relief as placebo, but with no actual effect.

Now comes the odd part.

If you type "gait trial" in Google in UK, the first hit is www.GAITtrial.co.uk. If you go to www.GAITtrial.co.uk you are presented with a very professional website, made to look like it has some affiliation with the GAIT trial mentioned above. However, there are only two pages and no details about who has written it or who they are representing, but it helpfully gives us a few links at the bottom to where we can purchase some glucosamine.

Firstly, the pages information is considerably more positive than the trial researchers indicated - in fact, it says the direct opposite; compare

Secondly, the links at the bottom of the page are suspect - the first two, for Boots and Health Perception don't work, but the third for Joint Care does and it takes you to the Seven Seas Joint Care "Everyone needs healthy joints" website, advertising all manner of glucosamine pills.

Is it a coincidence that only the Seven Seas link works? Well, possibly, but another website, also designed by Two's Company Design Studio Ltd, which discussed the GUIDE study , a small European study that gave weakly positive results for glucosamine, the same thing happens. As an observation, whoever "sabotaged" the links did so in two different ways on the two sites, implying that only one link is supposed to work - the Seven Seas one.

Is this Seven Seas gently directing people to its site using false, hyped-up information, but without explicitly having to make the claims themselves?

...there is very little medical evidence to back up the effectiveness of supplements, such as chondroitin and glucosamine. Although there is little medical evidence to back up the effectiveness of glucosamine hydrochloride, recent research has shown that taking glucosamine sulphate (which is found in healthy cartilage), or fish oils, may have positive results. However, the NHS cannot recommend, or prescribe, the use of glucosamine sulphate because it does not often prove to [be] cost-effective.

Hardly a resounding endorsement. So what is that "recent research"? Well, unfortunately, the NHS page doesn't give the reference, but I'll bet that it is probably the GAIT trial - The Glucosamine/Chondroitin Arthritis Intervention Trial, which was a large randomized, placebo-controlled trial conducted at several sites across the USA. The National Centre for Complementary & Alternative medicine (NCCAM, who were involved in the trial) in the US has an excellent Q&A.

The research has been going on for a number of years, and the first stage of the trial was published in 2006 in The New England Journal of Medicine which concluded:

Glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with osteoarthritis of the knee. Exploratory analyses suggest that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-to-severe knee pain

They freely admit that because of the small numbers in this subgroup, they were unable to to demonstrate statistical benefits, and requested further research.

In a funny "who do you believe?"-type story, Dr Trish MacNair was dealing out Doctor's advice on the BBC's Health Pages and in October 2007 (after this study came out, here advice was (in direct opposition to GAIT, the largest and most relevant study on the supplements):

Glucosamine seems to be less useful when a person has more severe pain from arthritis.

(As an aside, I found this line from the GAIT publication fascinating:

...the high rate of response to placebo (60.1 percent) and the relatively mild degree of pain from osteoarthritis among the participants may have limited our ability to detect benefits of the treatments. Elevated rates of response to placebo have been reported in other osteoarthritis trials and may relate, in part, to patients' biases and expectations and to the enrollment of patients with relatively mild symptoms of osteoarthritis.

I'm pretty sure we all know of people who have arthritis who swear by some secret natural pain-reliever such as honey & ginger hot drinks or cider vinegar - this study seems to suggest that we arthrites will respond well to a raft of placebos; anything to numb the pain! If it "works", that's excellent - stick with it. I have my own placebo, and I know it's a placebo, but a double of Highland Park Whisky with one piece of ice (just one, mind) seems to do the trick and it's more fun than cider vinegar).

Anyway, I'm rambling.

The next stage of the trial has now been released - it is due to be published in Arthritis & Rheumatism (paywalled, although Abstract here), and NCCAM's press release is here, and was interpreted by Reuters here. The results were as follows:

The researchers looked at the reduction in joint space width and found it had decreased less than they had expected which made the analysis more complicated. It's fair to say though that the scientific self-criticism that the press release acknowledges is something that we could do with seeing a lot more of in the CAM world this side of the pond.

They had 572 people for the study and it ran for a further 18 months after the first observation, giving a 2 year study span altogether. Director of the co-funder of the study, National Institute of Arthritis and Musculoskeletal & Skin Diseases, very sensibly said:

Research continues to reveal that osteoarthritis, the most common form of arthritis, appears to be the result of an array of factors including age, gender, genetics, obesity, and joint injuries.

or in other words "It's probably a bit more complicated than that", a phrase which should be used much, much more than it is.

At this point in time, none of the UK newspapers have picked up the story (from credit crunch to bone crunch?), although I did find out that Chesney Hawkes had some cartilege removed from his hip and guess what? He now takes glucosamine.

Keep Libel Laws out of Science

About Me

Who I am is largely irrelevant, and indeed so are most of my thoughts.
Nonetheless, it winds me up that I am supposed to swallow half-truths and untruths relating to scientific claims emanating directly from media sources and indirectly from people who haven't a clue what they're talking about.
Look, you've got me started.
(You can email me at thinkingisdangerousblog AT googlemail DOT com.)